<%@ include file="/common/taglibs.jsp"%>

<head>
    <title><fmt:message key="signup.title"/></title>
    <meta name="heading" content="<fmt:message key='signup.heading'/>"/>
</head>

<body id="signup"/>

<div class="separator"></div>

<s:form name="wellnessProfileForm" action="saveSharedWellness" method="post" validate="true">
    <li class="info">
        <fmt:message key="wellness.message"/>
    </li>


    <li>
        <div>
            <div class="left">
                <fmt:message key="q39.healthinterests"/>
                <s:checkbox key="shared.hiquitsmoking" name="shared.hiquitsmoking" fieldValue="1" cssClass="text large"/>
                <s:checkbox key="shared.hiweightmgt" name="shared.hiweightmgt" fieldValue="1" cssClass="text large"/>
                <s:checkbox key="shared.hiaerobics" name="shared.hiaerobics" fieldValue="1" cssClass="text large"/>
                <s:checkbox key="shared.hiwalking" name="shared.hiwalking" fieldValue="1" cssClass="text large"/>
                <s:checkbox key="shared.hijogging" name="shared.hijogging" fieldValue="1" cssClass="text large"/>
                <s:checkbox key="shared.hifitnesseval" name="shared.hifitnesseval" fieldValue="1" cssClass="text large"/>
                <s:checkbox key="shared.hinutrition" name="shared.hinutrition" fieldValue="1" cssClass="text large"/>
                <s:checkbox key="shared.hicholesterol" name="shared.hicholesterol" fieldValue="1" cssClass="text large"/>
                <s:checkbox key="shared.hibp" name="shared.hibp" fieldValue="1" cssClass="text large"/>
                <s:checkbox key="shared.hicoronaryrisk" name="shared.hicoronaryrisk" fieldValue="1" cssClass="text large"/>
                <s:checkbox key="shared.hialcoholdrug" name="shared.hialcoholdrug" fieldValue="1" cssClass="text large"/>
                <s:checkbox key="shared.hihealthyback" name="shared.hihealthyback" fieldValue="1" cssClass="text large"/>
                <s:checkbox key="shared.hiselfcare" name="shared.hiselfcare" fieldValue="1" cssClass="text large"/>
                <s:checkbox key="shared.histressmgt" name="shared." fieldValue="1" cssClass="text large"/>
                <s:checkbox key="shared.hicpr" name="shared.hicpr" fieldValue="1" cssClass="text large"/>
                <s:checkbox key="shared.hifirstaid" name="shared.hifirstaid" fieldValue="1" cssClass="text large"/>
                <s:checkbox key="shared.hihealtheval" name="shared.hihealtheval" fieldValue="1" cssClass="text large"/>
                <s:checkbox key="shared.hiwomenshealth" name="shared.hiwomenshealth" fieldValue="1" cssClass="text large"/>
                <s:checkbox key="shared.hidiabetes" name="shared.hidiabetes" fieldValue="1" cssClass="text large"/>
                <s:checkbox key="shared.hicommunication" name="shared.hicommunication" fieldValue="1" cssClass="text large"/>
            </div>
            <div>
            </div>
        </div>
    </li>

    
    
    <li class="buttonBar bottom">
        <s:submit key="button.save" cssClass="button"/>
        <s:submit key="button.cancel" name="cancel" cssClass="button"/>
    </li>
</s:form>

<script type="text/javascript">
    Form.focusFirstElement(document.forms["wellnessProfileForm"]);
</script>
